A comparison of drinking behavior using a harmonized methodology (Liq.In ⁷ ) in six countries

This study is the first time that drinking behavior, in terms of volume and fluid type, has been reported for these populations by including whether or not food was also consumed, either as a meal or outside of meals. We describe three distinct drinking behaviors: drinking with meals, drinking as a stand-alone activity and a type of ‘grazing’ (i.e., frequent drinking occasions throughout the day) behavior, which appear to be linked to social, cultural and dietary factors. This hypothetical link is based on the clear differences observed between countries. No comparable studies are available for Argentina, Brazil, Mexico, Uruguay or Indonesia, although there have been reports on drinking occasions from China. A study in schools in China showed that 71% of TFI are consumed outside meals [35], which is remarkably similar to the present study reporting 72%. However, Zhang [23] reported that 52% of the fluid drunk during meals was water compared with 37% in the present study. Water and fluid intake in China were quite different compared to the other countries in this analysis. The usual Chinese diet contains many dishes with a high water content (e.g., soups [36]); consequently, there is less need to drink fluid in order to chew and swallow food. The amount of total water intake derived from food in China has been estimated to be 40% [36] compared to 21% in Indonesia [37]. Data on the water provided by food in the diet of the Latin American countries included in this analysis were not available.

Chinese, Indonesian and Brazilian participants most frequently consumed fluids without food, while Mexican and Argentinian participants favored drinking with food, both during and between meals. The participants from Uruguay drank throughout the day, a behavior that may be described as ‘grazing’. Mate, a traditional hot infusion of the herb Ilex paraguayensis, is popular in Uruguay [31] and is consumed throughout the day, which may partly explain this behavior. Several studies have described drinking behavior during and between mealtimes [13, 25, 27, 38] and others have described drinking occasions across the day [23, 39]. As in the present study, differences between countries were observed: e.g., in France drinking is concentrated during meal times [25, 27, 40], whilst a Spanish study concluded that time of day had no effect [13] on drinking behavior. Social and cultural factors, such as purchasing resources, and environmental and fiscal conditions may have a role in determining the type of drinking habits in a particular country. However, this requires further study. In addition, more information is needed to be able to establish the importance of such habits and their relevance to health.

Water was the preferred drink when no food was eaten in all countries included in this study, except for Uruguay, which favored hot beverages, probably mate. However, there was more variation in the preferred type of drink when eating between meals. Eating food appeared to be a major determinant of fluid type choice especially during meals. To the best of our knowledge, only two other studies (both in children aged 4–17 years) have described the type of beverages according to meals and between meal occasions. A study of British children aged 4–13 years showed that 60% of fluids were consumed at meal times and that the drink of choice varied over the course of the day [38]. At breakfast the favored drinks were milk, 100% fruit juices and hot beverages; water-based fruit drinks (not 100% fruit juice) were favored at lunch, and fruit drinks, water, soda and milk at dinner time. Most SSBs were drunk at dinner time and in the afternoon. In contrast, a study in French children [40] showed that drinks were more likely to be consumed during meals than with the British children. Again, there was a variation in types of drink consumed across the day; milk was favored at breakfast, while water was favored at lunch and dinner. The consumption of SSBs was relatively low in both groups of children. It is difficult to make comparisons between the present study and these two aforementioned studies for many reasons including the differences in age groups studied, i.e., 4–13 years vs. populations that included children, adolescents and adults. Secondly, timings of meals and between meal periods were not recorded in the present study as the focus was on whether or not food was consumed at the drinking occasions at all. Conversely, whether or not food was consumed at a drinking occasion was not recorded in these former studies.

It is interesting to note that terminology has an impact on whether or not fluids are included in studies. For example, definitions of an eating occasion, a meal or, in particular, a snack vary and are often based on the energy contents of the snacks [41]. This may result in stand-alone drinking occasions not being recorded accurately, especially those in which energy is not consumed, e.g., plain water [41]. In the present study, drinking occasions when food was not consumed were variable, accounting for 32–55% of median fluid intake in the Latin American countries, 58% in Indonesia and 66% in China. These stand-alone occasions represent significant contributions to TFI, and energy intake however, they may have been ignored in some studies as no food was consumed [42]. Snacking has been shown to be increasing in many countries [21, 43, 44] and soft and carbonated drinks have been found to be the most popular drink/snack-combinations in some countries [45]. Encouragingly, some studies have recognized the importance of including drinks in such surveys [43, 45]. It is now pertinent to revise the definitions associated with the study of eating habits, particularly the definition of a snack, to accurately include drinking occasions regardless of energy content.

Most drinking occasions occurred at home for all of the Latin-American countries and Indonesia; in China less than half of the TFI was consumed at home. Similarly, it was found that for French children [40] most drinking occurred outside the home. The previously mentioned study of British children [38] found that most drinking occasions occurred at home although the greatest volume of fluid was consumed outside the home. The largest volume was consumed in full service restaurants followed by fast food restaurants; soda (regular and diet) was the preferred drink in both types of restaurant. This is in accordance with other studies, despite plain water often being available free-of-charge at full-service restaurants [17]. In the present study the contribution of SSB was largest at locations away from home, which contrasts with other studies that have found that most energy-dense beverages were consumed at home [20, 41]. Other studies [38, 40] have shown that water is consumed in the largest volumes in schools; however, these studies were conducted in countries that have legislation on what types of drinks are available in schools. Interestingly, [19] concluded that schools were a limited source of energy-dense beverages, especially when policies were in place to reduce their availability [46, 47]. However, these, and most other studies on this topic, have been conducted in USA, unlike the present intercontinental study. The influence of cultural and societal factors in drinking behavior requires further study. Encouragement of healthier drinking options, especially water, in schools and child care settings [48] will aid the development of healthy drinking behavior and facilitate education on this topic.

The present study has several strengths, not least the use of a validated methodology that captures all drinking occasions [34]. In addition, a harmonized survey methodology was used across all the studied countries that resulted in a population size of over 10,000 participants, which further strengthens the findings. The approach to categorize drinking occasions as to whether or not food was consumed, was innovative and facilitated interesting comparisons of cross cultural drinking behaviors. However, the sample size was insufficient to ensure a powerful analysis of fluid types according to locations. As with any form of dietary survey there is a potential for a selection bias, with people more interested in the research participating in the survey. In addition other factors that influence drinking behavior such as climate, level of education and physical activity have not been considered in this analysis.